Wiki Question regarding multiple conditions in the Assessment and Plan

[Svirgilio]

I need some help regarding counting additional conditions in the assessment and plan. If providers want credit for additional conditions in the assessment and plan should they document those conditions in the chief complaint along with the presenting problem or do they only need to be mentioned in the history of present illness? For example a few of our providers will document something like COPD as the presenting problem and then in the assessment and plan along with the COPD is hypertension and diabetes as the 2nd and 3rd with nothing about these conditions in the HPI. I explained to them that they need to make mention of the additional conditions in the HPI if they want credit for these conditions. A question came up as to whether those conditions also need to be documented in the chief complaint as well. I wanted to get some feedback regarding this issue.

 

[Titali80]

I don't think so. Correct me if I am wrong. Chief Complain is "what's the main reason pt. ended up being at Doctor's office or hospital" that's it.

 

[kbartrom]

Agree - the chief complaint is the reason for today's visit. The diabetes, etc certainly have an impact on the COPD and its treatment. I remind providers that HPI does not have to be in the beginning of the chart (tho for auditing purposes that's preferred!). If the first mention of diabetes is in the assessment I encourage them to say a bit about it there.